Home From the ICU but Not Recovered: Selecting Transitions Theory for a DNP Project on Post-Intensive Care Syndrome, With Criteria and Rejected Alternatives
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Doctor of Nursing Practice Program, Aspen University
DNP845: Theoretical and Scientific Underpinnings
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Month Day, Year
Home From the ICU but Not Recovered: Selecting Transitions Theory for a DNP Project on Post-Intensive Care Syndrome, With Criteria and Rejected Alternatives
Choosing a theoretical framework for a DNP project should be a reasoned decision, not a matter of familiarity. This paper states five criteria for selecting a theory, applies them to three candidates for a project on the transition home of adult intensive care unit survivors, and defends the choice of Meleis's transitions theory while explaining why Roy's adaptation model and Mishel's uncertainty in illness theory were not selected.
The Project and the Problem
Survivors of critical illness often go home with new or worsening problems. Post-intensive care syndrome, the name a national stakeholder conference agreed on, covers problems in movement and strength, thinking, or mood that are new or worse after critical illness and that last past the hospital stay; relatives can develop the mental health problems as well (Needham et al., 2012). At a composite 400-bed hospital, 38 percent of ICU survivors discharged home are readmitted or visit the emergency department within 60 days. The DNP project proposes a nurse-led transition program beginning before ICU discharge and continuing with home visits and telephone follow-up for eight weeks.
Selection Criteria
Fawcett and DeSanto-Madeya (2013) describe the evaluation of nursing theories in terms of significance, internal consistency, parsimony, testability, and empirical and pragmatic adequacy. Drawing on those ideas, five criteria were set for this project. First, fit: the theory must address the phenomenon at the center of the project, the movement from ICU to home. Second, explanatory power: it must help explain why some survivors do well and others do not. Third, guidance for intervention: it must point to what nurses should do. Fourth, testability: its concepts must be measurable in a project. Fifth, parsimony: it must be usable by the staff who will deliver the program.
Candidate 1: Roy's Adaptation Model
Roy's grand model views the person as an adaptive system responding to stimuli through physiological, self-concept, role function, and interdependence modes. It offers a comprehensive view of the person, and its four modes map well onto the physical, psychological, and family dimensions of post-intensive care syndrome. However, it performs poorly on three criteria. It does not center on transition, so it describes adaptation at any moment rather than the movement between settings. Its concepts are broad, making measurement difficult in a single project. And its breadth reduces parsimony for staff who need a clear guide. It was therefore not selected.
Candidate 2: Mishel's Uncertainty in Illness Theory
In Mishel's theory, uncertainty is what a person experiences when illness events cannot be made sense of: when their significance is unclear and what will happen next cannot be foreseen (Mishel, 1988). ICU survivors and families face considerable uncertainty about recovery, and the theory offers well-developed measures. It performs well on testability and fit with one part of the experience. But it addresses only one dimension of the transition, so it lacks the explanatory power to account for physical deconditioning, changed family roles, or access to follow-up care, and its guidance for intervention is limited to reducing or reappraising uncertainty. It would be a useful secondary lens but not the primary framework.
Selected: Meleis's Transitions Theory
Meleis et al. (2000) proposed a middle-range theory of transitions describing the nature of transitions, including their types and patterns and properties like the person's awareness of the change, how engaged they are with it, how long it lasts, and the critical points along the way; the personal, community, and societal conditions that facilitate or inhibit them; and patterns of response. Responses are read through two sets of indicators: signs during the transition that it is going well, among them a sense of connection, active engagement with others, and growing confidence; and signs at the end, chiefly mastery of new skills and an identity that has absorbed the change. Nursing therapeutics are directed at supporting healthy transitions.
The theory performs well on all five criteria. It fits the phenomenon directly, since leaving the ICU and returning home is a health-illness and situational transition with multiple critical points. It explains variation in outcomes through facilitating and inhibiting conditions, such as preparation, knowledge, family support, and access to resources. It guides intervention by pointing to critical points, such as ICU discharge, the first week home, and the first follow-up visit, where nursing support matters most. Its process and outcome indicators can be measured, for example through confidence in managing care and readmission rates. And its concepts are intuitive enough for staff. Transitions theory is chosen because it describes the very thing the project is trying to change: not the illness, but the passage through it.
How the Theory Shapes the Project
The project will use the theory's structure throughout. Assessment before ICU discharge will identify facilitating and inhibiting conditions, including the family's readiness, the home environment, and the patient's understanding of post-intensive care syndrome. Nursing therapeutics will be timed to critical points: a transition conference before transfer, a home visit within 72 hours of discharge, and weekly telephone contact for eight weeks. Process indicators will be tracked through a brief confidence measure, and outcome indicators through 60-day readmissions and emergency visits. Uncertainty, drawn from Mishel's theory, will be assessed as one inhibiting condition, so the rejected theory still contributes a measure.
Limits of the Chosen Theory
Transitions theory also has limits that the project must manage. Its concepts are descriptive and broad enough that different nurses may interpret facilitating and inhibiting conditions differently, so the project will use a structured assessment form to make them consistent. The theory does not prescribe specific nursing therapeutics, which means the content of each home visit must be drawn from post-intensive care evidence, such as screening for cognitive changes, depression, and physical decline, rather than from the theory itself. And outcome indicators such as mastery are harder to measure than readmissions, so the project will rely on a validated confidence scale as a proxy and report the limitation.
Conclusion
Selecting a theory for a DNP project is a decision that should be made against explicit criteria. Measured by fit, explanatory power, guidance for intervention, testability, and parsimony, Meleis's transitions theory best supports a nurse-led program for ICU survivors going home. Roy's adaptation model is too broad and Mishel's uncertainty theory too narrow for this purpose, although the latter contributes a useful measure. The chosen theory will shape the project from assessment to evaluation.
References
Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). F. A. Davis.
Meleis, A. I., Sawyer, L. M., Im, E.-O., Hilfinger Messias, D. K., & Schumacher, K. (2000). Experiencing transitions: An emerging middle-range theory. Advances in Nursing Science, 23(1), 12-28. https://doi.org/10.1097/00012272-200009000-00006
Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of Nursing Scholarship, 20(4), 225-232. https://doi.org/10.1111/j.1547-5069.1988.tb00082.x
Needham, D. M., Davidson, J., Cohen, H., Hopkins, R. O., Weinert, C., Wunsch, H., Zawistowski, C., Bemis-Dougherty, A., Berney, S. C., Bienvenu, O. J., Brady, S. L., Brodsky, M. B., Denehy, L., Elliott, D., Flatley, C., Harabin, A. L., Jones, C., Louis, D., Meltzer, W., ... Harvey, M. A. (2012). Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders' conference. Critical Care Medicine, 40(2), 502-509. https://doi.org/10.1097/CCM.0b013e318232da75
How this DNP 845 Module 4 example is structured
DNP845 Module 4 assignments frequently ask for a defended theory selection with rejection criteria stated. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example states criteria from a theory evaluation framework, judges three candidates against them, explains each rejection and shows how the selected theory shapes the project.
DNP845 Module 4 questions, answered
What does DNP845 Module 4 usually ask for?
The module frequently asks you to select a theoretical framework for your DNP project and defend the choice, stating the criteria you used and why alternatives were rejected. Aspen does not publish module deliverables, so your classroom's instructions govern.
What criteria should I use to select a theory?
Common criteria include fit with the phenomenon, explanatory power, guidance for intervention, testability of concepts and parsimony, drawn from established frameworks for evaluating nursing theories.
What is post-intensive care syndrome?
New or worsening impairments in physical, cognitive or mental health that arise after critical illness and persist beyond hospitalization. Family members can experience related mental health effects.
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